Corporate Medical Policy - GEHA
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Corporate Medical Policy
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Description of Procedure or Service
Palatopharyngoplasty refers to several surgical approaches for management of the upper airway,
including uvulopalatopharyngoplasty (UPPP), uvulopharyngoplasty (UPP), uvulopalatal flap, expansion
sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty and relocation
pharyngoplasty. UPPP, one of the most commonly chosen approaches, involves surgical resection of the
mucosa and submucosa of the soft palate, tonsillar fossa, and the lateral aspect of the uvula. The
amount of tissue removed is individualized for each patient as determined by the potential space and
width of the tonsillar pillar mucosa between the 2 palatal arches. The UPPP enlarges the oropharynx but
cannot correct obstructions in the hypopharynx. Thus, patients who fail UPPP may be candidates for
additional procedures, depending on the site of obstruction.
Background
Uvulopalatopharyngoplasty has been found to be most reliably effective in obstructive sleep apnea
(OSA) members who have adequately responded to a trial of continuous positive airway pressure (CPAP
or auto-adjusting CPAP (AutoPAP)). If CPAP or AutoPAP is unsuccessful in relieving a member's
symptoms, this may indicate that apnea is not due to obstruction. Thus, this surgical approach has not
been shown to be effective in non-obstructive apnea for persons who do not respond to CPAP or
AutoPAP.
Uvulopalatopharyngoplasty (UPPP): The largest of the reviewed studies of UPPP (n=95) was in a
randomized trial that evaluated UPPP versus nonsurgical treatment with a mandibular advancement
device. This trial provides limited evidence that the mandibular advancement device is more effective
than UPPP. Patients randomized to the device had statistically significant improvements in apnea index,
apnea-hypopnea index, and blood oxygen saturation, relative to patients randomized to UPPP; however,
38% of patients in the device treatment group were lost to follow-up or withdrew from the study due to
noncompliance before 4 years of follow-up were completed.
Another randomized trial of UPPP was conducted as part of two parallel, randomized studies in which
patients were assigned to CPAP (n=44) or UPPP (n=32) by a team of medical experts. Patients were then
randomized to treatment or no treatment. Although the results of this study suggest that UPPP and
CPAP reduced symptoms of sleep apnea, the design of this study prevents direct comparison of results
obtained with UPPP versus CPAP. Considering only the UPPP arm of the trial, this procedure was found
to provide statistically significant improvements in daytime sleepiness and snoring but not in decreases
in blood oxygen saturation levels during sleep.
One other randomized trial of UPPP met the criteria for detailed review and it compared UPPP with
lateral pharyngoplasty for obstructive sleep apnea-hypopnea syndrome (OSAHS). This study found that
lateral pharyngoplasty provided statistically significant improvements in daytime sleepiness and apnea-hypopnea index compared with UPPP; however, it was small (n=27) and involved only a mean 8 months
follow-up.
Uvulopalatoplasty (UPP): Only three studies of UPP met the criteria for detailed review, a retrospective
nonrandomized comparative study, a prospective case series, and a retrospective study. Outcome
measures in these studies varied and included apnea index, blood oxygen saturation during sleep,
daytime sleepiness, and snoring. In the nonrandomized comparative study, 63 patients with OSAHS
underwent UPP or UPPP; patients with redundant pharyngeal folds were assigned to UPPP. Patients also
underwent ablation of any redundant tonsillar tissue. Results of this study suggest that, when proper
patient selection criteria are used, UPP and UPPP provide comparable improvements in daytime
sleepiness and snoring. Snoring intensity decreased 67% after either treatment; however, daytime
sleepiness decreased only 31% after UPP and only 33% after UPPP. The reviewed prospective and
retrospective case series evaluating UPP do not provide conclusive evidence that this procedure is
effective since they were uncontrolled. Although the larger of these two case series (n=76) reported that
daytime sleepiness disappeared or decreased markedly for 66% of patients, the benefits of UPP seemed
to diminish somewhat over time. In addition, the smaller case series reported that less than half of
patients who underwent UPP had a > 50% improvement in apnea index
Regulatory Status
There are no regulatory specifics to note relevant to coverage of the titled procedures. However, there
are several regulated therapies associated with surgical management of upper airway symptoms which
may be mentioned in this coverage policy.
Benefit Application
This medical policy relates only to the services or supplies described herein. Please refer to the
member's benefit booklet for availability of benefits.
Coverage for orthognathic surgery is only eligible in accord with the member’s benefit brochure which
allows for the surgery only for the following conditions:
• Severe sleep apnea only after conservative treatment of sleep apnea has failed; or
• Cleft palate and Pierre Robin Syndrome.
Policy Statement
GEHA will provide coverage for palatopharyngoplasty procedures, including uvulopalatopharyngoplasty
or uvulopalatoplasty, when determined to be medically necessary because the medical criteria and
guidelines as documented below have been demonstrated.
For non-surgical treatment of obstructive sleep apnea, refer to GEHA’s clinical coverage policy for
obstructive sleep apnea at geha.com.
Origination Date: Feb. 2017 Peer Reviewed: Feb. 2019 Next Review Date: Feb. 2020When Palatopharyngoplasty/Uvulopalatopharyngoplasty is covered:
• GEHA considers Uvulopalatopharyngoplasty (UPPP) or uvulopalatoplasty (UPP) medically
necessary for the treatment of clinically significant (moderate to severe) obstructive sleep apnea
syndrome or upper airway resistance syndrome (UARS) in patients who have tried and failed a
good faith effort at treatment with continuous positive airway pressure (CPAP) or bilevel
positive airway pressure (BiPAP) and whose physical examination shows obstruction at the
palatal level.
Clinically significant OSA is defined as those patients who have:
• An apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) of > 15
per hour, or
• An AHI or RDI of > 5 per hour in a patient with excessive daytime sleepiness or
unexplained hypertension.
Clinically significant UARS is defined as greater than 10 alpha EEG respiratory arousals per hour.
The presence of abnormally negative intrathoracic pressures (i.e., more negative than -10 cm) in
conjunction with the EEG arousals supports the diagnosis. Measurement of intrathoracic
pressures requires the use of an esophageal manometer as an adjunct to a polysomnogram.
Objective evidence of hypopharyngeal obstruction is documented by either fiberoptic
endoscopy or cephalometric radiographs.
• Uvulopalatopharyngoplasty may also be indicated in order to enhance CPAP or BiPAP
effectiveness in patients who have tried and failed a good faith effort at pressure support.
When Palatopharyngoplasty/Uvulopalatopharyngoplasty is not covered:
GEHA considers the following procedures for the treatment of OSA to be experimental:
• Adult Lingual or Pharyngeal Tonsillectomy as an isolated procedure
• Trans-palatal Advancement Pharyngoplasty
• Expansion Sphincteroplasty
• Lateral Pharyngoplasty
• Laser-assisted Uvulopalatoplasty (LAUP)
• Radiofrequency Ablation of Palatal Tissues and the Tongue
• Tongue Base Suspension or Reduction
• Palatal Stiffening
• Cautery-Assisted Palatal Stiffening Operation (CAPSO)
Origination Date: Feb. 2017 Peer Reviewed: Feb. 2019 Next Review Date: Feb. 2020• Palatal Implants
• Implantable Hypoglossal Nerve Stimulators
• Somnoplasty and Coblation
• Uvulectomy
• Injection snoreplasty
• All “minimally invasive” surgical procedures for OSA not specifically identified as covered above
Policy Guidelines
Conservative measures must have been tried and failed prior to considering surgical management for
OSA or Upper Airway Resistance Syndrome. Conservative medical therapy, when appropriate to the
clinical situation, may include: weight loss, avoidance of alcohol, sedatives and caffeine consumption-
especially before bedtime, allowing adequate sleep time, body position during sleep (side versus back),
oral appliances, positive airway pressure devices and medically supervised smoking cessation programs.
GEHA considers positive airway pressure (e.g., CPAP, BiPAP) as the treatment of choice for obstructive
sleep apnea based upon current medical practice standards. For this reason the general rule is that a
good faith effort at positive pressure must be tried and failed prior to coverage of surgical treatment.
Surgery is to be reserved for patients who have not responded to appropriate medical alternatives.
Physician documentation
For any request for prior review of a surgical procedure, current polysomnogram data (including the
initial sleep study, any CPAP titration data, and any other studies such as MSLT that have been
performed) must be submitted for review with the supporting medical record documentation.
Generally, the sleep study upon which approval is requested must be less than 18 months old.
Polysomnography data must include a summary with, at minimum, the following information:
• Total sleep time for the study;
• Total RDI or AHI for the study;
• Average and lowest recorded oxygen saturation;
• For any desaturations below 90%, the length of time at the abnormally low saturation level or
range;
• Obstructive event indices for supine and non-supine positions, along with total sleep time
spent supine;
• Periodic leg movement (PLM) index;
• A summary table of the polysomnogram results and titration data for all devices used.
A polysomnogram that does not distinguish between supine and non-supine obstructive events, to the
extent that any possible positional predisposition to obstruction can be determined, may not be
sufficient to support a request for surgery or pressure therapy; GEHA reserves the authority to seek
Origination Date: Feb. 2017 Peer Reviewed: Feb. 2019 Next Review Date: Feb. 2020clarifying information. GEHA may also require a repeat polysomnogram to support any request for additional surgical therapy after an approved surgical therapy based on an initial polysomnogram. Scientific references American Academy of Otolaryngology-Head and Neck Surgery. Position Statement on Uvulopalatopharyngoplasty. 2012; http://www.entnet.org/Practice/policyUvulo.cfm. Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. Oct 1 2010;33(10):1408-1413. PMID 21061864 Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Radiofrequency volumetric tissue reduction for sleep-related breathing disorders. TEC Assessments. 2000; Volume 15, Tab 15 Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: A systematic review and meta-analysis. Sleep. 2010;33(10):1396-1407. Certal VF, Zaghi S, Riaz M, et al. Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. May 2015;125(5):1254-1264. de Paula Soares CF, Cavichio L, Cahali MB. Lateral pharyngoplasty reduces nocturnal blood pressure in patients with obstructive sleep apnea. Laryngoscope. 2014;124(1):311-316. Dizdar D, Civelek S, Calis ZA, et al. Comparative analysis of lateral pharyngoplasty and uvulopalatopharyngoplasty techniques with polisomnography and Epworth sleepiness scales. J Craniofac Surg. 2015;26(7):e647-e651. Farrar J, Ryan J, Oliver E, et al. Radiofrequency ablation for the treatment of obstructive sleep apnea: a meta-analysis. Laryngoscope. Oct 2008;118(10):1878-1883. PMID 18806478 Ferguson KA, Heighway K, Ruby RR. A randomized trial of laser-assisted uvulopalatoplasty in the treatment of mild obstructive sleep apnea. Am J Respir Crit Care Med. Jan 1 2003;167(1):15-19. PMID 12502473 Fernandez-Julian E, Munoz N, Achiques MT, et al. Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. Jun 2009;140(6):917-923. PMID 19467415 Friedman M, Schalch P, Lin HC, et al. Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. Feb 2008;138(2):209-216. PMID 18241718 Handler E, Hamans E, Goldberg AN, et al. Tongue suspension: an evidence-based review and comparison to hypopharyngeal surgery for OSA. Laryngoscope. Jan 2014;124(1):329-336. PMID 23729234 Hayes Medical Technology Directory (October 30, 2018). Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea. Retrieved January 21, 2019. Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479–504. Origination Date: Feb. 2017 Peer Reviewed: Feb. 2019 Next Review Date: Feb. 2020
Karakoc O, Akcam MT, Genc H, et al. Do pharyngeal surgeries for snoring and obstructive sleep apnea have an impact on nasalance scores? J Craniofac Surg. 2015;26(7):2213-2216. Mair EA, Day RH. Cautery-assisted palatal stiffening operation. Otolaryngol Head Neck Surg. Apr 2000;122(4):547-556. PMID 10740176 Pang KP, Terris DJ. Modified cautery-assisted palatal stiffening operation: new method for treating snoring and mild obstructive sleep apnea. Otolaryngol Head Neck Surg. May 2007;136(5):823-826. PMID 17478223 Soares D, Sinawe H, Folbe AJ, et al. Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery. Laryngoscope. 2012;122(2):473-479. Steward DL, Huntley TC, Woodson BT, et al. Palate implants for obstructive sleep apnea: multi- institution, randomized, placebo-controlled study. Otolaryngol Head Neck Surg. Oct 2008;139(4):506- 510. PMID 18922335 Strohl KP. Overview of obstructive sleep apnea in adults. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed November 2014. Strollo PJ, Jr., Soose RJ, Maurer JT, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. Jan 9 2014;370(2):139-149. PMID 24401051 Wassmuth Z, Mair E, Loube D, et al. Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. Jul 2000;123(1 Pt 1):55-60. Peer Reviewed by MRIoa Feb. 2017 Next Review Date: Feb. 2018 Woodson BT. Transpalatal advancement pharyngoplasty outcomes compared with uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 2005;133(2):211-217. Policy implementation and updates 2/2018 Revised to include expanded title and additional clarity around pre-surgical management of OSA. 2/2019 Changed name to reflect surgical procedures for snoring and OSA. Aligned with OSA clinical coverage policy for experimental and investigational technology. Origination Date: Feb. 2017 Peer Reviewed: Feb. 2019 Next Review Date: Feb. 2020
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